White Oak Manor - Charlotte

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, and staff and Medical Director interviews, the facility failed to correctly transcribe a verbal physician's order for twice daily blood sugar checks resulting in no blood sugar checks being performed

during a resident's admission. This affected 1 of 3 residents reviewed for services provided meet professional standards (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE REDACTED] with diagnoses which included sepsis, diabetes mellitus, failure to thrive and end stage renal disease which required hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so) three times weekly.A review of Resident #3's electronic medical record revealed a physician verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice daily. Resident #3 was not on any diabetic medication.A care plan dated 9/10/2025 indicated Resident #3 had a diagnosis of diabetes mellitus and was at risk for complications related to the disease process with a goal that Resident #3 would not experience any complications of diabetes mellitus. Interventions included monitor for signs and symptoms of hyperglycemia (high blood sugar), monitor for signs and symptoms of hypoglycemia (low blood sugar), and obtain lab work as ordered.A review of Resident #3's electronic medical record (EMR) indicated no record of blood sugar being drawn from the date of admission 9/5/2025 to discharge 9/10/2025. An interview on 10/1/2025 at 4:40 PM with the Director of Nursing (DON) revealed that the physician's verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice a day had been provided to Nurse #2 by the Medical Director. The DON indicated when Nurse #2 entered the verbal order, Nurse #2 neglected to choose an option under the Flow Sheet box (treatment versus medication) which resulted in the order never being displayed on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). The DON stated a blood sugar was not taken while Resident #3 was a resident. The DON stated orders written within the last 24 hours are reviewed by nursing staff for accuracy and she was not sure why the transcription error was not discovered.An interview on 10/1/2025 at 5:08 PM with Nurse #2 indicated she took the verbal order for check blood sugar twice a day from the Medical Director. Nurse #2 stated she was new to entering orders and made a mistake when entering the order.An interview on 10/1/2025 at 5:43 PM with the Administrator indicated that all physician orders should be entered correctly.An interview on 10/2/2025 at 8:40 AM with the Medical Director revealed Resident #3 was a very sick individual and had an extended hospital stay prior to admission to the facility. The Medical Director stated the verbal order dated 9/5/2025 at 9:12 PM for check blood sugar twice daily was provided as Resident #3 had a history of low blood sugar episodes while in the hospital prior to admission to the facility. The Medical Director stated Resident #3 was not on any diabetic medication. The Medical Director indicated that all orders should be transcribed correctly.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

White Oak Manor - Charlotte

4009 Craig Avenue Charlotte, NC 28211

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in the room and trash in the trash can. NA #2 stated she observed Resident #1's ultraviolent insect trap in his room with insects inside, on the trap. She explained that she removed the trash from his room and tried to clean up as much as she could but also housekeeping staff had come by to assist. Hospital records dated 08/23/25 revealed Resident #1 was admitted into the hospital on this date due to generally feeling weak and the need for increased oxygen. Upon assessment in the hospital Resident #1 was noted to have left lower extremity venous ulcers and blisters to the mid left shin. Resident #1 was admitted and treated for sepsis to chronic venous statis ulcer and returned to the facility on 9/12/25. On 09/30/25 at 4:06 PM an

interview was conducted with the Director of Nursing (DON). During the interview she stated Resident #1's wounds were always dressed and cleaned. The DON explained on 08/23/25 Resident #1 had experienced

a change of condition and was sent to the hospital. The DON stated she had physically seen small flies or gnats in Resident #1's room on one occasion due to a half-eaten banana. She explained Family Member #1 had asked to bring in an ultraviolent insect trap in August 2025 because of insects in his room. She explained Resident #1 never wanted to eat outside of his room and would always eat snacks in the room.

Environmental staff were completing extra rounding to attempt to keep the room clean and meal trays were removed immediately with completion of the meal. The DON stated the Maintenance Director completed pest control rounding and the main issue that arose were ants not gnats or flies. On 10/01/25 at 10:32 AM

an interview was conducted with the Maintenance Director. The Maintenance Director stated he did not keep a log of every time an issue with insects was reported. He stated if there was an issue with flies or gnats he would just go directly to the room and spray to take care of the concern. He stated the facility had

a contract with a pest control company that came out monthly to spray the facility. The interview revealed he could not recall being told there was a concern with flies or gnats in Resident #1's room. On 10/02/25 at 9:25 AM an interview was conducted with the Director of Housekeeping. During the interview she stated Resident #1's room was always cleaned twice a day and throughout the day because of trash and debris in

the room. She explained the residents in the room would keep dirty napkins and snack bags in the room.

The Director of Housekeeping stated the room would smell and she had observed gnats in the room and a couple of flies. She stated she had let the Maintenance Director know about the situation and if she saw food open, she would place it in a bag to try to eliminate the insects that were attracted to the area because of food items. On 10/01/25 an interview was conducted with the Pest Control Representative. The Representative stated the Pest Control company had most recently been to the facility in September and prior to that was in the facility on 08/13/25 to treat rodent stations and in the kitchen area due to cockroaches. No flies or gnats were mentioned in the report. The interview revealed the Pest Control company had no record of issues with flies or gnats from the facility. A continuous observation on 09/30/25 and 10/01/25 revealed small, winged gnats in the facility conference room. An interview conducted on 10/01/25 at 5:00 PM with the Administrator revealed he was new to the facility and was not aware of a fly or gnat problem. He stated there should be no flies or gnats in resident rooms to create a safe, comfortable environment for the residents. The Administrator acknowledged the gnats in the conference room during the conversation.

Event ID:

Facility ID:

If continuation sheet